Awake Craniotomy Anesthesia: A Comparison between the Monitored Anesthesia Care (MAC) versus the Asleep-Awake-Asleep (AAA) Technique

Background and Objective:
Awake craniotomy (AC) with intraoperative brain mapping, allows for maximum tumor resection while monitoring neurological function.
Used for lesions involving the eloquent areas of the brain, such as Broca`s, Wernicke’s, or the primary motor area.
Common techniques - monitored anesthesia care (MAC), using an unprotected airway, or the asleep-awake-asleep (AAA) technique, using a partially or totally protected airway.

Methods:
Approved by the appropriate Institutional Review Board (IRB), requirement for written informed consent was waived by the IRB.
A prospective data collection and subsequent retrospective data analysis was conducted on eighty one patients who underwent an awake craniotomy for an eloquent brain lesion over a 9 year period.
Fifty patients underwent anesthesia with the monitored anesthesia care (MAC) technique and thirty one patients underwent the asleep-awake-asleep (AAA) technique by a single surgeon and a team of anesthesiologist
Scalp Block: performed in all patients.

Results:
Similar preoperative patient characteristics (Table 1).
Operative time shorter in the MAC group(283.5 mins.) versus the AAA(313.3 mins., p=0.038), by about 30 minute
Hypertension most common intraoperative complication (MAC: 8% vs AAA: 9.7%, p=0.794).
Intraoperative seizures incident 4% in the MAC group and 3.2% in the AAA group (p=0.858).
Awake cases conversion to general anesthesia in none of the MAC group and 3.2% of the AAA cohort (p=0.201). No cases were aborted in either cohort (Table 2).
Mean hospital stay was 3.98 and 3.84 days in the MAC and AAA group(p=0.833). (Table 3).

Conclusion:
Both MAC and AAA provide safe and effective anesthetic management for awake craniotomy.